Health Canada Santé Canada Social Accountability A Vision for Canadian Medical Schools
Our mission is to help the people of Canada maintain and improve their health. Health Canada This publication can be made available in/on computer diskette/large print/audio cassette/braille, upon request. For additional copies, please contact: Publications Health Canada Ottawa, Ontario K1A 0K9 Tel.: (613) 954-5995 Fax: (613) 941-5366 Ce document est aussi offert en français sous le titre : Imputabilité sociale Une vision pour les facultés de médecine du Canada Her Majesty the Queen in Right of Canada, represented by the Minister of Public Works and Government Services Canada, 2001 Cat. No. H39-602/2002 ISBN 0-662-66388-8
Social Accountability A Vision for Canadian Medical Schools
Steering Committee Members Paul Cappon Co-chair (Council of Ministers of Education Canada) Robert McMurtry Co-chair February to September, 2000 (Health Canada) Jean Parboosingh Co-chair from September 2000 (Health Canada) Richard Cruess (McGill University) Sylvia Cruess (McGill University) David Hawkins (Association of Canadian Medical Colleges) Brian Hennen (University of Manitoba) Paul Grand Maison (University of Sherbrooke) Jason Kur (Canadian Federation of Medical Students) Noni MacDonald (Dalhousie University) Nadia Mickael (Royal College of Physicians and Surgeons of Canada) William Rowe (McGill University) Robert Shearer (Health Canada) Joshua Tepper (Canadian Association of Interns and Residents) Mo Watanabe (University of Calgary) Michael Whitcomb (Association of American Medical Colleges) Carl Whiteside (University of British Columbia) Robert Woollard (University of British Columbia) Don Ling (PEI Ministry of Health and Social Services) -1-
Executive Summary The Steering Committee on Social Accountability of Medical Schools adapted the concept of social accountability, which has been promulgated by the World Health Organization (WHO) over the past decade, to produce a vision for Canadian medical schools. The expectation of the public is that governments and the professions work collaboratively to ensure that the highly valued Canadian health care system continues to provide the necessary access and quality to meet the needs of the population. Medical schools have an important role to play in this endeavour. WHO has defined the Social Accountability of Medical Schools as the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve. The priority health concerns are to be identified jointly by governments, health care organizations, health professionals and the public. A set of principles of social accountability by which Canadian medical schools should function include: Medical schools emphasize to their faculty and students the need to maintain their competence, the importance of the patient-physician relationship, and an understanding of professionalism and its obligations. Medical schools conduct curiosity-driven research and provide evidence-based care, testing new models of practice that translate the results of research into practice. Medical schools work together and in partnership with their affiliated health care organizations, the community, other professional groups, policy makers and governments to develop a shared vision of an evolving and sustainable health care system for the future. Involvement of the community in identifying community needs, setting priorities, establishing and evaluating new models of practice is seen as critical. The role of the medical schools and their partner organizations in education, research and service is articulated within the social accountability framework and the need for the medical community at large to understand and demonstrate the concept of professionalism is underlined. The development of an effective social accountability model for medical schools will provide the basis for all partners to work collectively on meeting the needs of the Canadian population in a collegial and collaborative manner. Medical schools respond to the changing needs of the community by developing formal mechanisms to maintain awareness of these needs and advocate for them to be met. -2-
Introduction At the beginning of the new millennium, the expectation of the public is that governments and the professions work collaboratively to ensure that the highly valued Canadian health care system continues to provide the necessary access and quality to meet the needs of the population. Medical schools have an important role to play in this endeavour. By identifying and responding to the needs of the community, whether defined by risk or by geography, and by ensuring that individual graduating physicians understand their role in society, Canadian medical schools, along with their partners, have a major role to play in influencing the changes in the health care system that are necessary to ensure an effective, efficient, accessible, equitable and sustainable system in the 21 st century. namely education, research and service. Academic freedom and clinical autonomy are other values entrenched within the Canadian academic and clinical communities, which must be weighed in any assessment of the role and functions of medical schools. The definition of social accountability of medical schools is the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve. The priority health concerns are to be identified jointly by governments, health care organizations, health professionals and the public. WHO, 1995 Concepts of Social Accountability and Social Responsiveness WHO has defined the Social Accountability of Medical Schools as the obligation to direct their education, research and service activities towards addressing the priority health concerns of the community, region, and/or nation they have a mandate to serve. The priority health concerns are to be identified jointly by governments, health care organizations, health professionals and the public. Social responsiveness is a complementary capability by which a medical school responds to societal needs and acts proactively to meet those needs. WHO has developed a framework designed to help medical schools evaluate their progress towards achieving the goal of social accountability. This framework addresses the four values of social accountability, relevance, quality, cost effectiveness and equity, as they pertain to the activities of medical schools, The relevance of the activities of medical schools implies that they, together with governments, the profession and other major stakeholders in the health care system, have a systematic approach to addressing priority health needs, including issues of access to services, determining and educating the appropriate number and mix of physicians, and facilitating the geographic distribution necessary to meet the needs of the community. High quality health care is evidence-based, comprehensive and culturally sensitive; the definition of quality, however, may vary over time and be dependent on the availability of resources. Thus, setting priorities and ensuring the cost effectiveness of care are important mechanisms by which medical schools, in partnership with other key stakeholders, can demonstrate their responsiveness to societal needs at a local level. Equity means striving to make quality health care available to all people; medical -1-
schools can assist by defining populations at risk through well-designed research, identifying methods of removing barriers to access and educating students in environments in which they are exposed to those in need. These values are implicit in the Canadian health care system and are recognized by the Canadian population at large, which is, today, better informed and more demanding of better access and quality for the health care system. At this time of reinvestment in health by governments, an explicit acknowledgement by Canadian medical schools that these are important issues for them, will show how they are in a unique position and are prepared to play a major role in seeking to contribute to the sustainability of the health care system into the future. the optimal preparation of future practitioners to respond to population needs; the establishment and promotion of innovative practice patterns to better meet individual and community needs; the reinforcement of partnerships with other stakeholders, including academic health centres, governments, communities and other relevant professional and non-professional organizations; advocacy for the services and resources needed for optimal patient care; the definition and clarification of the concept of social accountability and the dissemination of methods for measuring responsiveness to societal needs; A Vision: The Leadership Role of Canadian Medical Schools While recognizing the role of governments and others in providing funding for health care services and for research and education, medical schools can play a leadership role in helping to contribute, in partnership with a wide variety of other parties and agencies, in the following areas: Canadian medical schools are in a unique position and are prepared to play a major role in seeking to contribute to the sustainability of the health care system into the future. the development of a clear and shared vision of the health care system and of the health care providers of the 21 st century. This vision will have to be clearly articulated and constantly revised to respond to changing needs; the inclusion of the concept of social accountability in the accreditation process of medical schools and other health institutions. Medical schools exist within a larger health and social system, which involves all determinants of health including wealth, education, the environment, housing and a spectrum of services from health promotion to palliative care. There are many health care providers, in addition to physicians, who have obligations to meet societal needs. Principles of Social Accountability The following set of principles by which Canadian medical schools should function is suggested. These will allow medical schools to identify where they stand with respect to responding to the needs of society and to continuously strive to ensure that they are doing so. Formal measurement of the social accountability of medical schools requires -2-
considerable resources. In a substantially publicly funded medical education and health care system such as exists in Canada, medical schools work in partnership and in a climate of collegiality and collaboration to contribute to the health and well-being of the people and the communities they serve by incorporating the following principles: Medical schools emphasize to their faculty and students the need to maintain their competence, the importance of the patient-physician relationship, and an understanding of professionalism and its obligations. Medical schools respond to the changing needs of the community by developing formal mechanisms to maintain awareness of these needs and advocate for them to be met. Medical schools conduct curiosity-driven research and provide evidence-based care, testing new models of practice that translate the results of research into practice. Medical schools work together and in partnership with their affiliated health care organizations, the community, other professional groups, policy makers and governments to develop a shared vision of an evolving and sustainable health care system for the future. The balance between community relevance and the unfettered search for and transmission of knowledge is never a quiet one but an unambiguous dedication to the welfare of our collective future is part of the social responsibility of medical schools and academic health care organizations (the academic health sciences centres). Canadian society provides medical schools and the medical profession with certain privileges and resources; these are justified only insofar as they are unambiguously placed in the service of those in need and the community of which they are a part. The primary goal of medical education is to prepare graduates to practice effectively in reducing the burden of illness and improving the health of their communities. This goal includes the concept of professionalism, i.e. the social contract between a professional and society, with its core values of scientific expertise and altruism. In order to meet this social contract, professionals in training should be equipped with the knowledge, skills and resources to meet societal needs. The core values of professionalism (the social contract between professional and society) are scientific expertise and altruism. Social Commitment and Community Engagement Medical schools should explicitly expound their commitment to social accountability and social responsiveness in their general orientation, including in their publicly-stated mandate or mission statement. They should proactively define these concepts and identify the actions to be implemented in order to demonstrate their commitment to be socially accountable and responsive. Included in these actions is fostering the engagement of the community in their activities. The public, as consumers, are demanding more of all providers of consumer products and services; this is reflected in the increasing demands on the health care system to meet the needs of each and every person who uses the system. Identifying community needs, -3-
setting priorities, establishing and evaluating new models of practice are areas in which community participation is critical. opportunity are more effective strategies for encouraging physicians to meet the needs of society than are coercive measures. The Role of Medical Schools Medical schools function in three major arenas: education, research and, usually with other partners, in health care provision. In addition, they are expected to manage their resources, relate to policymakers and other stakeholders and be proactive and innovative in all aspects of their work, thereby helping to shape the external world in which they exist. A well-rounded professional demonstrates: knowledge, clinical competence, lifelong learning, evidencebased practice, interdisciplinary teamwork, balance between disease management and disease prevention/ health promotion, professional and ethical behaviour in practice, optimal use of resources and consciousness of well-being of self and colleagues. 1. Education Canadian medical schools are responsible for undergraduate, postgraduate and continuing medical education as well as the training of future health scientists. The need to inculcate the concepts of lifelong learning into teaching and learning across all levels is increasingly being recognized. The content of educational programs should be directed towards the priority health problems in all sectors of the community, both hospital-based and community-based, and to the range of health issues from health promotion to palliative care. The role of the medical schools in postgraduate training is key to the production of a well-trained and appropriate generalist : specialist mix of practitioners to meet the need of the Canadian health care system. To achieve this, a national approach to physician resource planning is necessary in Canada. This requires that medical schools collaborate with the federal, provincial and territorial governments and the other national medical educational and licensing bodies to ensure that the right number and mix of physicians enter practice. To this end, it is recognized that individual volition and enhancement of Medical schools have the obligation to ensure that their learning environments respond to the ever-increasing knowledge base, but equally to ensure that they produce well-rounded professionals. This includes ensuring that students and residents understand the contributions of other health care disciplines and have the ability to practice within an interdisciplinary team. A philosophy that values health promotion and disease prevention as components of medical care and an assumption that physicians have a responsibility in health promotion and disease prevention are important to future practitioners. In addition to their role in educating medical professionals, as knowledge expands and health care becomes increasingly complex, medical schools have an obligation to impart that knowledge to the public as do individual physicians to their patients. -4-
2. Research A balance between the freedom to carry out curiosity-driven research and research directed to meeting the needs of the community is essential, as is the need for a long term vision of research that encompasses multiple settings and a collaborative approach. As the scope of medical research is expanding, funding for research has increased significantly. Medical schools must meet the challenge of a changing research paradigm that includes areas that have not been of paramount interest to academic researchers, while maintaining a leadership role in the traditional research arena. The goal is to be responsive to the current and emerging needs of their individual communities, within the larger context of national and international trends, by continually profiling the health status and health care needs of the community. While basic science and clinical and health services research have been priorities for medical schools, research in population health becomes ever more important to identify the needs of the communities served by medical schools. Where needs are identified, mechanisms to meet those needs must be put into place; this may mean that medical schools take the initiative to develop and implement interventions in collaboration with community health groups and other sectors to improve the health care and health status of the communities they serve. Evaluation research is key to ensuring that such interventions meet identified needs and to providing a strong evidence base for sustainability. Evaluation research into educational techniques and processes also needs to be promoted so that the most effective means of educating students, faculty and the community are developed. Basic biomedical research creates new knowledge and understanding of molecular and cellular mechanisms of health and disease and the biological pathways to the determinants of health. Discoveries and development in this arena have the potential, through technology transfer, to contribute to commercialization and the creation of jobs. Applied clinical research is involved in the evaluation of the safety and efficacy of new and existing drugs, treatments and procedures and thus contributes to the protection of the health of all Canadians and to the quality of care provided. Health services research evaluates the care of individual patients and of new delivery models of community-based and system-based care. As new models of delivery of primary care are implemented, health services research will play an important part in evaluating the impact of its individual components, such as interdisciplinary care, alternate funding mechanisms and registration of patients. At a systems level, health services research can contribute by evaluating the care provided in integrated systems of care, such as cancer care networks. As the use of information technology and telehealth expands, research will be needed to demonstrate their impact on the health care system in terms of quality, access and cost-effectiveness. Medical schools and the social mechanisms that fund research have an obligation to recognize the potential influence that pecuniary considerations can have on the priorities of the research endeavour. Medical schools have a particular responsibility to be beyond reproach in conducting themselves in such a way that the unfettered search for knowledge is not unduly influenced by factors other than the needs of society. -5-
3. Provision of Health Care In addition to the role that they play in education and research, the part time and full time faculty of all medical schools are involved in the provision of clinical services, usually under the aegis of an affiliated health care institution. This arises in part because of the very nature of medical education and clinical research but also reflects the active partnerships with other institutions and communities that are the legitimate responsibility of medical schools engaged in assessing and responding to community needs. Provision of tertiary and quaternary care to the community are almost exclusively within the purview of the health care organizations linked to a medical school forming the academic health sciences centre. Participation by medical schools in secondary and primary care reflects the learning environment required to appropriately educate physicians for community service. The whole of the learning environment for a medical school constitutes the academic health sciences network. A balanced integration of service and education, regardless of which sector of the health care system it takes place in, is essential to ensure the well-being of trainees and that the appropriate educational outcomes are achieved. Support for the establishment of innovative practice patterns and participation in defining and shaping the health care system of the future are other valued contributions that can and should be attributed to medical schools. This future orientation needs the establishment of partnerships with external health care institutions and policy makers. Active, thoughtful engagement with other medical organizations responsible for certification, regulation and advocacy is part of the expression of a medical school s partnership obligation. Similarly a broad engagement with the health care system and the communities in which it is embedded is a necessary basis for the expression of its social responsibility. Professionalism Professionalism is the moral understanding among professionals that underpins the concept of a social contract between the profession and the public; under this contract, professional occupations have been granted authority to self-regulate and independence to control key aspects of their working conditions through accreditation, licensing, credentialing and professional conduct review. The call to professional responsibility must be an articulate one that applies equally well to practising members of the profession as it does to those in training. The call to professional responsibility applies equally well to practising members of the profession as it does to those in training. Professionalism of Individuals Medical schools should ensure that individual physicians graduate aware that the profession of medicine is one of constant change and, thus, they need to be lifelong learners. Methods need to be in place to demonstrate that graduates have achieved an understanding of the concept of professionalism. Graduates need to be prepared to demonstrate their competence in an ever-changing environment, to ensure that their practice is based on evidence and to respond to the changing environment in which they practice. This includes recognition of the role of the patient in the patient-physician interaction, advocacy on behalf of the patient, the willingness to work -6-
in a variety of settings where need exists for medical services and recognition of the roles of other health care professionals. Professionalism of Medical Schools Faculty and medical schools must be able to demonstrate that the outcomes of their activities in these arenas make a difference. They have the obligation to demonstrate to society that they produce physicians who recognize their role in society and that the application of their education, research and service activities have a positive impact on the health care and health status of the population they serve. Potential Outcomes Faculty and graduates of Canadian medical schools will embrace their social responsibility through the provision and promotion of health for all individuals and groups. This requires a knowledge of and engagement with marginalized and vulnerable individuals and communities who will need unique strategies in order to facilitate accessibility to health care. Faculty and graduates will recognize the critical importance of the following concepts: community consultation and community inclusion in the entire health care enterprise, disease prevention and health promotion, integrated and interdisciplinary care, lifelong learning and continuing professional development, performance measurement and research. Faculty and graduates will foster collegial attitudes that promote interdisciplinary and multidisciplinary approaches to health care and ensure meaningful exchange with other professions. An explicitly articulated recognition by the medical schools that they are listening and responding to their various publics is important to increasing the confidence of the governments and the public that the resources spent on them are justified. One approach is for individual medical schools to carry out specific projects consistent with a renewed emphasis on social accountability. Governments will be more likely to recognize the importance of this work, the medical community will be more satisfied with their working conditions and more motivated to put forth additional efforts on behalf of their patients. The development of an effective social accountability model for medical schools will provide the basis for all partners to work collectively on meeting the needs of the Canadian population in a collegial and collaborative manner. The explicit incorporation of social accountability within the fabric of medical faculties will provide a basis for development of respectful partnerships for health with government, health authorities, communities and business. These partnerships will facilitate and encourage shared work on health planning, problem solving, health service delivery, health service evaluation and health policy development. The development of an effective social accountability model for medical schools provides a pattern for other professions and partners in health to develop similar social accountability frameworks. It also provides the basis for all to work collectively on meeting the needs of the Canadian population in a collegial and collaborative manner. -7-
Bibliography Defining and measuring the social accountability of medical schools; Division of Development of Human Resources for Health, World Health Organization, Geneva, Switzerland; 1995. Code of Ethics of the Canadian Medical Association, http://www.cma.ca/inside/policybase/1996/10-15.htm; 1996. Doctors for Health: A WHO global strategy for changing medical education and medical practice for health for all. World Health Organization, Geneva, Switzerland; 1996. CapponP&Watson D. Improving the Social Responsiveness of Medical Schools: Lessons from the Canadian Experience. Academic Medicine. 1999; 74(8): S81-S90. Gastel B. Improving the Social Responsiveness of Medical Schools: Summary of the Conference. Academic Medicine. 1999; 74(8): S3-S7. Boelen C. Adapting Health Care Institutions and Medical Schools to Societies Needs. Academic Medicine. 1999; 74(8): S11-S20. Universities and the health of the disadvantaged. World Health Organization, Geneva, Switzerland; 2000. Towards Unity for Health: Challenges and opportunities for partnership in health development. World Health Organization, Geneva, Switzerland; 2000. -8-